Genetics of Chiari I Malformation. Syringomyelia is most often associated with Chiari I malformation. The process by which the Chiari I malformation develops is unknown. Ectopia of the cerebellar tonsils (through the foramen magnum at the base of the skull), the defining characteristic of the Chiari I malformation, may result from abnormal development of the posterior fossa. In a clinical study of families with multiple members affected by the Chiari I malformation, we are using magnetic resonance imaging of the brain to evaluate for Chiari I malformation and to measure the size of the osseous structures and volume of the posterior fossa. After phenotyping family members as being affected or unaffected by these traits, we collect DNA specimens from them for genotyping. During the past 3 years, in collaboration with our Associate Investigator Joan Bailey-Wilson, M.D., Ph.D., we have submitted 113 DNA samples of affected and control individuals for Whole Exome Sequence (WES) under the NHGRI NISC-funded flagship project. The samples originated from families in Russia and the United States with multiple members affected by Chiari I malformation. Currently the substantial amount of data is being analyzed. This data set consisted of whole exome data from 10 extended families with a total of 132 individuals (including samples that were previously sequenced). Preliminary filtering was performed by removing markers with a depth of less than 10, a quality score of less than 10, or a ratio of quality score to depth of less than 0.5 using the Golden Helix software. Further filtering was performed using p-link; markers that were only genotyped in two people or less were removed, as were monomorphic markers. Sib-pair was used to remove any markers with Mendelian errors. All cleaning resulted in a total of 560,134 markers. Several dummy individuals were added to connect disjointed pedigrees. To perform multi-point analyses, the markers were mapped onto the Rutgers Map, version 3. Two point linkage analyses were performed using the program TwoPointLods. The genetic model used for the program was a disease allele frequency of 0.01 with a penetrance of 0.01/0.01/0.0 (meaning no phenocopies). Multi-point analyses will be performed using SimWalk2 and annotation will be performed with the ANNOVAR software tool. Tentative results from two point linkage analyses have shown that family 22 is the most promising with several regions with LOD score above 1.5. In particular, chromosome 1 has regions with the highest LOD scores between 1.5-1.9. WES identified non-synonymous Single Nucleotide Variations (SNVs) in the exonic and UTR regions of the gene ISG15 (ISG15 ubiquitin-like modifier), RER1 (RER1 retention in endoplasmic reticulum 1 homolog) and NPHS2 (steroid-resistant podocin). None of these genes have previously been associated with neurologic or skeletal maldevelopment. These represent very promising candidate for further investigation. At this point, multi-linkage analyses and whole genome annotation for each family are being performed by our collaborators at the NHGRI. This would aid in further narrowing down SNVs that are most likely novel causative variants. Once we have a complete list of candidate SNVs, Sanger sequencing will be performed by laboratories at the Surgical Neurology Branch to confirm the variant identified on WES. We then anticipate performing functional studies of the protein of interest to further elucidate if it is the causative variant. Finding one or more genetic loci that are associated with the Chiari I malformation would lead to a better understanding of the etiology of the Chiari I malformation. Treatment of Syringomyelia. A natural history study of patients with syringomyelia was initiated 5 years ago in which patients will be monitored annually for 5 years with neurological examinations, standard scales of pain and function, and MRI of thebrain and spine. Patients receive specialized care for their condition, including surgery if necessary. This study will better define the outcome of patients with syringomyelia and will provide preliminary data to generate hypotheses for future hypothesis-driven studies. This year the study was amended to increase the protocol enrollment ceiling to 180 from the previous 120 subjects. Additional subjects were necessary because 17 of 120 subjects had withdrawn from the study and we needed to replace these study dropouts and because more patients were needed to evaluate the natural history of various subgroups in the study, which now include: a) Chiari I malformation alone, observation subgroup; b) Chiari I malformation alone, surgical treatment subgroup; c) Chiari I malformation with syringomyelia, observation subgroup; d) Chiari I malformation with syringomyelia, surgery subgroup; e) non-Chiari related syringomyelia, observation subgroup; and f) non-Chiari related syringomyelia, surgery subgroup. The study will be completed when all subjects finish 5 years of follow-up. Four years ago we reported a study that evaluated the morphologic features of the cerebellum and medulla oblongata before and 3-6 months after surgery in patients with Chiari I malformation and syringomyelia. After surgery that expanded the posterior fossa, the abnormal shape of the cerebellum and medulla oblongata characteristic of the Chiari I malformation changed to a more normal appearance. These findings support the concept that the Chiari I malformation arises from lack of development of the posterior fossa rather than a primary neural abnormality. We published a paper this year with Linge et al. describing the physiologic changes in CSF flow at the foramen magnum that occur after surgical treatment in patients with Chiari I malformation. Three years ago we also published a clinical study of the pathophysiology of primary spinal syringomyelia, a type of syringomyelia not associated with Chiari I malformation. A preliminary finding was that obstruction of the spinal subarachnoid space in primary spinal syringomyelia was associated with enlarged cerebrospinal fluid (CSF) pressure waves superior to the obstruction. Successful surgery for primary spinal syringomyelia opened CSF pathways, reduced CSF pressure waves to normal and resolved syringomyelia, as had successful surgery in our studies of Chiari I-type syringomyelia. This association suggests that primary spinal syringomyelia and Chiari I-type syringomyelia arise from a similar mechanism.